eMedicine Specialties > Ophthalmology > Neurologic Disorders

Trigeminal Neuralgia: Follow-up

Author: Marc E Lenaerts, MD, Clerkship Director, Assistant Professor, Department of Neurology, University of Oklahoma
Coauthor(s): James R Couch, MD, PhD, FACP, Professor of Neurology, University of Oklahoma Health Sciences Center
Contributor Information and Disclosures

Updated: Mar 17, 2006

Follow-up

Further Inpatient Care

  • Except for surgical procedures, trigeminal neuralgia is not an affliction to treat on an inpatient basis.

Further Outpatient Care

  • Longitudinal follow-up care is important because of the chronicity of the disease and because many treatments fail to maintain their efficacy (eg, pharmacologic, procedural).
  • Monitor treatment for adverse effects. Monitoring of blood levels is advised in the case of carbamazepine or phenytoin (ie, monthly for at least 3 mo for carbamazepine, once after 2 wk for phenytoin) and every time the dose is adjusted or adverse effects appear.
  • In the case of carbamazepine, a CBC should be performed every month for 3 months to rule out bone marrow suppression.
  • Monitoring patients after procedures or open skull surgery will help screen for complications, such as corneal abrasions and anesthesia dolorosa.
  • Transcranial magnetic stimulation appears promising, but results are still scarce.

Deterrence/Prevention

  • Percutaneous procedures and surgery yield the best results when applied early in the course of the disease. Even if medical treatment comes first, trials, when they are adequately completed and ineffective, should be followed promptly by the next trial in order not to delay and decrease the efficacy of more invasive treatments.
  • No specific preventative therapy exists. Patients may suffer from a premonitory atypical pain for months; therefore, appropriate recognition of this pretrigeminal neuralgia syndrome may lead to earlier and more efficient treatment.

Complications

  • A partial destruction of the nerve due to procedures and, sometimes, surgery can result in anesthesia dolorosa, a condition where pain is still present but sensation is decreased. Whether pain is or is not present, the decreased pain perception can lead to lesions that remain unnoticed to the patient.
  • Corneal ulceration can result because of trophic disturbances from nerve deafferentation. Therefore, assessing the integrity of facial sensation immediately before and after a procedure, as well as in the long term, is paramount.
  • After any invasive treatments, reactivation of a herpes simplex infection is not uncommon.

Prognosis

  • Idiopathic trigeminal neuralgia is a chronic affliction and needs constant follow-up care; however, its disease course does not progressively worsen.

Patient Education

  • Patients should be aware of potential adverse effects. They should report any altered sensation in the face, especially after a procedure.
  • Patients should be educated about the importance of being compliant with their medication regimen. They should be informed about the potential for anesthesia dolorosa.
  • Patients should be informed that carbamazepine is not prescribed (at this time) for a seizure disorder.
  • For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education articles Trigeminal Neuralgia (Facial Nerve Pain) and Tic Douloureux.

Miscellaneous

Medicolegal Pitfalls

  • Neoplastic infiltration of the nerve should not be overlooked. (A case of lymphoma revealed by trigeminal neuralgia has been seen.)
  • Failure to diagnose a brainstem tumor and bone marrow aplasia as an idiosyncratic adverse effect of carbamazepine are common pitfalls to avoid. Standard care must be applied to invasive procedures, which are most subject to potential claims.

Special Concerns

  • Anesthesia dolorosa should be a main special concern.
 


More on Trigeminal Neuralgia

Overview: Trigeminal Neuralgia
Differential Diagnoses & Workup: Trigeminal Neuralgia
Treatment & Medication: Trigeminal Neuralgia
Follow-up: Trigeminal Neuralgia
Multimedia: Trigeminal Neuralgia
References
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References

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Further Reading

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Keywords

tic douloureux

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Contributor Information and Disclosures

Author

Marc E Lenaerts, MD, Clerkship Director, Assistant Professor, Department of Neurology, University of Oklahoma
Marc E Lenaerts, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Merck and OrthoMcNeil Neurologics Honoraria Speaking and teaching

Coauthor(s)

James R Couch, MD, PhD, FACP, Professor of Neurology, University of Oklahoma Health Sciences Center
James R Couch, MD, PhD, FACP is a member of the following medical societies: American Academy of Neurology, American Geriatrics Society, American Headache Society, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, American Stroke Association, and United Council of Neurologic Subspecialties, Certification in Headache Medicine
Disclosure: Nothing to disclose.

Medical Editor

Andrew W Lawton, MD, Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center
Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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